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Apri. 11, 2021

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  • Be aware of five cases of acute non-viral hepatitis of unknown etiology in children ranging in ages from seven months to five years with a potential link to "Real Water" brand products.
  • Counsel patients to stop drinking, cooking with, or using "Real Water" brand products until more is known about the cause of the illnesses per FDA recommendations.
  • Educate patients on the signs and symptoms of acute hepatitis due to any cause and the importance of seeking medical care.
    • Symptoms include fever, fatigue, loss of appetite, nausea, vomiting, abdominal pain, dark urine, light-colored stools, joint pain, and yellow skin or eyes
  • Maintain a high index of suspicion for non-viral hepatitis in your differential diagnosis of acute hepatitis in patients, particularly young children, presenting with compatible clinical findings.
  • Obtain a detailed exposure history in patients when you suspect acute non-viral hepatitis.
    • Possible etiologies include exposure to medications, contaminated water or food, dietary and herbal supplements, traditional or home remedies, wild-growing mushrooms and plants, and chemicals such as metals, solvents, paint thinners, or pesticides.
  • Obtain early consultation with and/or referral to a gastroenterologist or infectious disease specialist for medical workup and management of patients with signs and symptoms of acute hepatitis.
  • Report cases of acute non-viral hepatitis of unknown etiology to Public Health – Seattle & King County at 206-296-4774.
  • Contact Washington Poison Center at 1-800-222-1222 to report any cases and for information on chemical or drug-induced liver toxicity.

On March 13, 2021, the U.S. Centers for Disease Control and Prevention (CDC) and the U.S. Food and Drug Administration (FDA) were notified by the Southern Nevada Health District of five cases of acute non-viral hepatitis of unknown etiology in children ranging in ages from seven months to five years. These cases presented to a hospital between November 10, 2020, and December 3, 2020, with signs and symptoms of vomiting, poor food intake, and fatigue. Laboratory testing on the patients showed elevated transaminases, hyperbilirubinemia, coagulopathy, and a negative viral hepatitis serology panel. Several adults and other children living in the cases' households reported similar but mostly less severe symptoms including nausea, vomiting, anorexia, and fatigue.

Preliminary investigation indicates a strong link between these cases and the consumption of "Real Water" alkaline water. Real Water is available in 5-gallon, 3-gallon, 1 gallon, 1.5 liters, 1 liter and 500 mL bottles, and "Real Water" concentrate can be purchased online and in stores nationwide. Real Water, Inc. has voluntarily issued a recall on their products, though the FDA reports that products are still available through online retailers. FDA also advises that Real Water not be given to pets.

To date, no cases of acute non-viral hepatitis of unknown etiology have been reported to WA Department of Health or Public Health – Seattle & King County.